PD E2- lung and thorax

where is needle insertion for a tension pneumothorax?

2nd ICS

where is chest tube insertion?

4th or 5th ICS; literally/mid to anterior axillary

where is the lower margin of endotracheal tube placement?

T4

where are neurovascular structures?

under each rib

where are needles and tubes placed?

superior to rib margins

which ribs articulate w/ the sternum?

first 7 ribs

what ribs articulate w/ costal cartilage above?

8-10

what are the floating ribs?

11-12

Where is the apex?

2-4 cm above the ribs, sits above the clavicle anteriorly

where is the minor fissure?

parallels right 4th rib

where is oblique fissure?

spans T3- 6th rib MCL

How do you perform pulm exam if patient can’t sit up?

roll pt 45 degrees and abduct/flex arm

What is carina?

bifurcation of trachea; anterior - 3rd ICS, posterior- T4

Which bronchus is shorter and more horizontal?

right main bronchus

What can nitrofurantoin cause?

interstitial lung disease

what is consolidation?

• occur when alveoli are not filled w/ air

• no breath sounds

• fremitus is inc

• crackles- pulmonary edema, fibrosis, chronic bronchitis

• pneumonia and bronchial obstruction- fever, dyspnea, cough

What is suspected w/ sx of community acquired pneumonia w/o signs of consolidation or negative CXR?

atypical pneumonia- mycoplasma, chlamydia, legionella

What should you encourage CAP patients to do?

ambulate, use incentive spirometer, take deep breaths and cough up sputum

what should you think of w/ frank blood in sputum?

TB or cancer

Who is hilar lymph node enlargement normal in?

children; NOT normal in adults

What is pleural effusion?

• fluid build up bt pleural space and lungs

• auscultation unable to hear sound → like putting head underwater at beach

• dullness to percussion

• absence of breath sounds

• fremitus is absent

what is the order for the lung physical exam?

inspect, palpate, percuss, auscultate

what is normal cap refill?

< 2 s

what would you hear on auscultation w/ tracheal deviation?

stridor

What is Oliver’s sign?

tracheal tug; downward displacement of cricoid cartilage w/ ventricular contraction → aortic arch aneurysm

what is Campbells sign?

tracheal tug; downward displacement of cricoid cartilage during inspiration → COPD

Describe a tension pneumothorax

• trachea deviation toward side AWAY from pain

• tympany and dec breath sounds

• STAT needle decompression

Describe massive pleural effusion

• tracheal deviation toward side AWAY from pain

• dullness and decreased breath sounds

• emergent thoracotomy

describe obstructed bronchus w/ atelectasis

• toward side of pain

• dullness and decreased breath sounds

• urgent/emergent

How do you check respiratory rate?

count while pretending to count the pulse; do NOT let pt be aware you are counting their respirations

What are examples of chest asymmetry abnormalities?

• kyphoscoliosis

• larger hemithorax- pneumothorax, pleural effusion

• smaller hemithorax- atelectasis, pleural fibrosis, agenesis of lung

What are examples of conditions with increased pleural negative pressure?

unilateral: airway obstruction

bilateral: COPD/asthma; intercostal and supraclavicular fossa retraction, downward movement of trachea w/ quiet inspiration

What is normal chest expansion?

2.5” and symmetrical

how do you measure chest expansion?

• measure at level of 10th rib

• pt sit erect or stand with arms to side

• grab lower hemithorax on either side of axilla and bring thumbs midline

• pt slowly take deep breath and expire

• watch for symmetry and feel expansion

• repeat anteriorly

what are conditions that would have decreased chest expansion?

• diffuse lung and pleural dz- emphysema

• stiff thorax- ankylosing spondylitis

• diaphragmatic paralysis

what conditions are seen w/ asymmetric chest expansion?

• kyphoscoliosis

• unilateral loss of lung volume- atelectasis, resection, pleural fibrosis

• unilateral space occupying lesions- pneumothorax, pleural effusion, large mass

• unilateral lung or pleural disease

what is a normal breathing pattern?

12-20 per minute resting w/ no apparent discomfort; chest wall and abdomen expand during inspiration and movement is symmetrical

What rate is considered bradypnea and what conditions might it be seen?

< 12

narcotics, elevated intracranial tension, myxedema

what rate is considered tachypnea and what conditions might it be seen?

> 20

interstitial and vascular dz, anxiety

What is orthopnea and what conditions might it be seen?

supine position worsens SOB

CHF, diaphragmatic paralysis, SVC syndrome, anterior mediastinal mass, body habitus

what is cheyne stokes breathing pattern?

progressively deeper and sometimes faster w/ gradual dec that results in temporary apnea

assoc w. dec level of consciousness and inc age

caused by CHF

what is kussmaul breathing pattern?

rapid deep breathing

assoc w/ ketones on breath

causes: DKA, metabolic acidosis, ketoacidosis, ethanol

what is Biot’s breathing pattern?

irregular w/ periodic apnea (no pattern)

assoc w/ dec level of consciousness

cause: CNS injury- brainstem

what is sighs breathing pattern?

periodic deep breathing

cause: anxiety

what is pursed lip breathing pattern?

lips pursed, controls expiration slowly

cause: obstruct lung dz

what is sleep apnea breathing pattern?

apnea w/ sleeping

assoc w/ morning HA, snoring, inc size of neck/tonsils

cause: obesity, retrosternal goiter

what is abdominal paradox breathing pattern?

abdomen retracts while chest expands

cause: diaphragmatic paralysis

what is thoracic paradox breathing pattern?

unstable chest wall side, hemithorax retracts while normal side expands w/ inspiration

assoc w/ trauma

cause: flail chest

describe breathing pattern w/ no abdominal component

no abd breathing

assoc w/ pain

cause: acute abdomen

describe breathing pattern w/ no thoracic component

no thoracic breathing

assoc w/ pain

cause: pleurisy, chest wall pain, ankylosing spondylitis

What are fremitus features associated w/ non obstructed consolidation?

increase fremitus over the area

what are fremitus features assoc w/ obstructed consolidation?

decreased or absent fremitus over the area

What are fremitus features associated w/ pleural effusion?

decreased fremitus at inferior part; thin rim of inc fremitus at superior rim

What are fremitus features associated w/ lobectomy and pneumonectomy?

absent

when does tactile fremitus increase?

when density of lung tissue increases

(pneumonia, neoplasm, solid mass)

when does tactile fremitus decrease?

when lung space is occupied w/ fluid/air

(pneumothorax, pleural effusion, COPD)

What is vocal fremitus?

patients voice heard through stethoscope (normally sounds indistinct)

what does abnormal vocal fremitus indicate?

consolidation

what is bronchophony?

99 stated by patient

what is egophony?

pt verbalizes letter E

what is whispered pectoriloquy?

99 whispered by pt

what is normally heard w/ percussion?

resonance

What is diaphragmatic excursion?

measures descent of diaphragm w/ respiration; normal- 3-5.5cm

what is consolidated lung disease?

solid mass (like sponge soaked w/ maple syrup) inflammation due to bacteria filling alveolar spaces

what is effusion?

fluid bt lung and chest wall; compresses normal lung → no sounds over effusion

what is obstructive lung disease?

bronchioles become degraded and floppy; air trapped w/ exhalation due to positive pressure causing bronchioles to close (blebs)

what is pneumothorax?

if chest wall puncture or if one of alveoli pop, air is introduced in between chest wall and lungs, air is trapped there and will accumulate

what conditions are dull w/ percussion?

consolidated lung disease and effusionw

what conditions are hyper resonant w/ percussion?

obstructive lung disease and pneumothorax

describe vesicular sounds

• heard in periphery of lungs (lung tissue)

• inspiration is long

• expiration almost not audible, no pause bt inspiration and expiration

• I:E ratio is 1:3-1:5

• gentle signing or gentle rustling

describe bronchial sounds

• heard over tracheobronchial tree

• loud and high pitched

• normal when heard over manubrium

• if present in periphery → may mean consolidation or pneumonia

• sound of air blowing through hallow pipe

describe bronchovesicular sounds

• heard over large central airways

• pitch bt tracheal and vesicular

• normal when auscultated near mainstream bronchi in 1st-2nd ICS and posteriorly bt scapula

• if heard elsewhere, consider atelectasis or early consolidation

what is a wheeze?

high pitched hissing or shrill; continuous and musical

what is a rhonchi?

low pitched, snoring quality; continuous and musical; clears w/ coughing

what adventitious sounds are continuous?

wheezes and rhonchi

** longer than crackles, musical in nature

what adventitious breath sounds are discontinuous?

fine and course crackles

**intermittent, non musical and brief

what are fine crackles?

soft, high pitched and very brief; intermittent, non musical

sounds like crushing fine leaves, velcro, or crinkling

what are course crackles?

explosive loud, lower in pitch; intermittent, non musical, brief

sounds like hair being rubbed by the ear or salt crackling on a heated dish

what conditions are wheezes assoc w/?

• asthma, COPD, bronchitis

• CHF

• CF

• vocal cord dysfunction

• FB aspiration

• tumor

• infections- croup, laryngitis

what conditions are assoc w/ rhonchi?

• seen in young and elderly

• caused by secretions in large airways

• adults- pneumonia or chronic bronchitis

• kids- RSV

what causes crackles?

caused by air bubbling through secretions or sudden explosive openings of airways

describe early inspiratory crackles

clears w/ cough; doesn’t change w/ posture

seen in COPD or bronchitis

describe late inspiratory crackles

doesn’t clear w/ cough; may change w/ posture; heard in bases and inferior regions

seen in pneumonia, pulmonary hemorrhage, CHF

Describe pleural friction rub

sound of 2 inflamed surfaces sliding by each other;

loud, heard over a small area; sounds like a hand over a wet balloon

describe stridor

loud musical sound heard at a distance; obstruction of trachea or larynx

seen in aspirations, URI, tracheomalacia, whooping cough, epiglottitis, croup

How does chronic bronchitis typically present?

• rough sounds

• airway obstruction

• breath sounds are loud due to obstructions

How does lobar pneumonia typically present?

• bronchial nature of sounds

• affects large continuous area of a lobe

• palpation- increased fremitus

• percussion- dull over the dense, airless lung

• auscultation- bronchial breath sounds, crackles, egophony, whispered pectoriloquy, and ronchi heard

how does a pneumothorax present?

• inspection- possible tracheal deviation to opposite side

• palpation- absent fremitus

• percussion- hyper resonant

• auscultation- absent breath sounds

what is terminal congestion / death rattle?

secretions in airway → produces crackles

if profuse, can be heard in mouth as well as chest

What are causes of pseudo cyanosis?

amiodarone, methemoglobinemia

what is clubbing?

peripheral trapping of large immature platelets and platelet clumps in capillary beds; promotes angiogenesis and bone growth; determine w/ lovibond’s angle at base of nail and surrounding skin